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Advance ventilation 1 cure or support
- 1. Cure or Support Fakhir Raza SIUT
- 3. Buffering • CO2 + H2O H2CO3 - H+ + HCO3-
- 4. Buffering • Should we buffer the hypercapneic acidosis • hypercapnia and intracranial hypertension. • higher pulmonary artery pressures • ACIDOSIS itself can cause impaired cardiac contractility, prolonged QT interval, decreased systemic vascular resistance, and hyperkalemia. • Neutrophilic activity against bacterial infection is also attenuated with hypercapnia
- 5. In Summary • Permissive hypercapnia is a proven strategy for reducing VILI in patients with severe respiratory failure, be it due to ARDS or obstructive diseases like asthma or COPD. To state it simply, it's more important to prevent iatrogenic lung injury than to get "normal" gas exchange. The degree to which permissive hypercapnia has a clinical benefit beyond preventing volutrauma remains to be seen, but the existing literature suggests that this may be the case
- 6. Takeaway Points Regarding Permissive Hypercapnia • Pay attention to tidal volumes. For ARDS, 4-6 mL/kg PBW is recommended. For obstructive airway diseases, 6- 8 mL/kg PBW is recommended. Exceeding these thresholds may increase the risk of VILI. • High respiratory rates may bring the pH up and the PaCO2 down, but this may be harmful due to repetitive cycling of vulnerable lung units. • Acidemia in itself may be beneficial in critical illness by augmenting blood flow and tissue oxygen delivery. • Look beyond the pH—consider buffer therapy, high respiratory rates, and alternative ventilator strategies only if the acidosis seems to be causing problems like intracranial hypertension, pulmonary hypertension, impaired cardiac contractility, refractory hyperkalemia, and systemic hypotension.
- 7. Level of PaO2 and Saturation
- 8. Benefit or harm • PaO2 of 65 vs PaO2 of 95 • Don't hurt the patient any more than you have to • Do what's necessary, not whatever is possible. • Tracheotomize early • How much PEEP 5 - 10 – 15 - 20 (optimal PEEP)
- 9. Optimal PEEP • How much PEEP 5 - 10 – 15 - 20 (optimal PEEP) • Decremental PEEP Trial (Recruit, Reduce , and Recruit) • PV Tool
- 10. PV tool
- 11. Transpulmonary pressure • PEEP – Pleural Pressure • It determines alveolar filling
- 14. How to measure Transpulmonary Pressure • Esophageal Baloon
- 15. Driving Pressure • Platue – PEEP
Editor's Notes
- The elimination of the excess CO2 produced by this reaction is not normally an issue—one or two breaths are sufficient to clear it. In the setting of severe respiratory failure, however, elimination of the CO2 may not be possible and the pH may in fact fall with the administration of sodium bicarbonate. In addition, CO2 diffuses freely over cell membranes (including in the CSF), but HCO3 - does not. This has the effect of worsening intracellular acidosis, even if the systemic pH rises. A transient hemodynamic improvement is often seen when a bolus of sodium bicarbonate (e.g., an "amp") is given, but this is more likely due to the loading of sodium than the change in pH—similar effects are seen with bolus dosing of hypertonic saline. Keep in mind that the NaHCO3 given in a 50 mL ampule is 8.4%, which is a very hypertonic sodium solution.